Browsing by Author "Noseworthy, Tom W."
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Item Open Access The Cost-Effectiveness of a Prevention Strategy for Clostridioides difficile Infections in Alberta Health Services(2019-04-30) Leal, Jenine Rocha; Manns, Braden; Henderson, Elizabeth Ann; Conly, John M.; Ronksley, Paul Everett; Loeb, Mark; Noseworthy, Tom W.The clinical and economic burden of hospital-acquired Clostridioides difficile infection (HA-CDI) is significant, however there is uncertainty in the cost-effectiveness of implementing probiotics for the primary prevention of HA-CDI among hospitalized patients prescribed antibiotics. In this thesis we examined the predictors of mortality and length of stay among this patient population in Alberta. We determined the attributable cost of HA-CDI and applied these estimates in a cost-effectiveness analysis of probiotics for the primary prevention of HA-CDI in Alberta from the perspective of a publicly-funded healthcare system. We conducted three studies: a population-based, retrospective cohort study using clinical surveillance, administrative and laboratory databases to determine the predictors of 30-day all-cause and attributable mortality and length of stay; a propensity score-matched study to compare patients with HA-CDI to patients without CDI to determine the attributable cost of HA-CDI in Alberta; and a cost-effectiveness analysis using decision analytic modelling to evaluate the costs and consequences related to probiotic use for the primary prevention of CDI. We found that the incidence and mortality rates of HA-CDI are declining, though the latter was not statistically significant. Advancing age was associated with all outcomes after adjusting for a number of baseline factors. Increased baseline white blood cell counts were associated with a lower risk of mortality. Hospital-acquired CDI total adjusted costs were 27% higher and length of stay was 13% higher than non-cases of CDI. Oral probiotics as a preventive strategy for CDI resulted in a lower risk of CDI and cost-savings. Previous studies on the burden of HA-CDI have been limited in their size and scope. Our first study was the largest population-based cohort study evaluating predictors of mortality; while our second study was the first to use propensity score-matching and a micro-costing approach for the estimation of costs associated with HA-CDI. We were the first to conduct an economic evaluation of probiotics for the primary prevention of CDI. This work will be presented to Alberta Health Services to support the evaluation of probiotics as a preventive strategy against CDI and whether to scale up probiotics to all provincial hospitals.Item Open Access A Health Technology Reassessment of Red Blood Cell Transfusions in the Intensive Care Unit(2019-08-23) Soril, Lesley Jeanne Josephine; Noseworthy, Tom W.; Clement, Fiona M.; Stelfox, Henry Thomas; Zygun, David A.Health technology reassessment (HTR) is the systematic, evidence-based assessment of the clinical, economic, ethical, and social impacts of an existing health technology to inform its optimal use. A novel model to guide HTR processes has been proposed. The overall aim of this thesis was to test the HTR model in a real-world healthcare context with the technology of red blood cell (RBC) transfusions in the intensive care unit (ICU). This thesis is comprised of 4 studies. The first study was a retrospective observational study of RBC transfusions in 9 Alberta ICUs. Between April 1, 2014 and December 31, 2016, we found that 61% of included RBC transfusions in stable, non-bleeding ICU patients were associated with a pre-transfusion hemoglobin value of 70 g/L or more and cost an estimated $1.82M in healthcare costs. Second, we conducted a systematic review and meta-analyses to determine the effectiveness of interventions on healthcare providers’ RBC transfusion practices. We identified a large and heterogenous body of evidence. Use of any intervention was associated with reduced odds of transfusion, including inappropriate transfusions. However, there was limited understanding of why interventions were selected over others and how this may have affected outcomes. In the third study, we conducted a population-based cross-sectional survey of Alberta ICU physicians to understand their perceptions of RBC transfusions practices using the Theoretical Domains Framework. We identified self-reported facilitators and barriers to practicing a guideline-recommended restrictive RBC transfusion strategy, which could then be mapped to relevant behaviour change interventions to optimize RBC transfusions. Finally, we conducted a controlled before and after pilot study to assess the feasibility of implementing a multi-modal intervention to optimize RBC transfusions in the ICU. The intervention was theory-informed and co-designed with local clinical leaders and included group education and audit and feedback. Early and meaningful stakeholder engagement and tailoring the intervention to interdisciplinary healthcare providers were important for achieving feasibility. Overall, we uncovered critical methodological and practical considerations to advance the emerging field of HTR. With regards to optimizing RBC transfusions, we established the necessary foundation to implement, monitor, and evaluate a larger-scale HTR initiative for ICUs in Alberta.Item Open Access Reassessment of Health Technologies: Obsolescence and Waste(Canadian Agency for Drugs and Technologies in Health, 2009) Joshi, Nikhil P.; Stahnisch, Frank W.; Noseworthy, Tom W.Item Open Access A Value Driven, Co-designed Framework for Sustained Patient Engagement(2019-04-22) McCarron, Tamara L.; Marlett, Nancy J.; Noseworthy, Tom W.; Hassay, Derek N.; White, Deborah Elizabeth; Lorenzetti, Diane L.; Bryan, Stirling; McCaughey, DeirdrePatient involvement in various aspects of healthcare, from improving healthcare quality to promoting patient safety, has emerged as a critical priority, but understanding how best to engage patients is not well-understood. This knowledge gap results in frustrating barriers for decision-makers looking to draw transferable lessons to inform the design of patient engagement programs and processes. Coupled with challenges to the sustainability of health care and the need for innovative solutions, patient engagement has become central to improving both quality and delivery of services. This thesis is comprised of three independent studies that form an overarching program of research. The first study reports the results of a scoping review to understand how health systems are investing in building the capacity and ability of patients. In the second study, we build on the findings from the scoping review and a series of qualitative interviews to inform a provincial survey tool to understand the motivations of individuals who chose to give their time and talents to health organizations. In the third study, we co-designed a framework for patient engagement, grounded in market choice behaviour theory and informed by the literature, a province-wide survey and four provincial stakeholder workshops. While significant research exists that highlights the motivations of the public who choose to participate in decision-making, a limited number of studies have explored these concepts within healthcare. As the roles of patient and family members in the context of healthcare decision-making continue to evolve, the importance of effective and sustainable engagement programs will become increasingly important. A deeper knowledge of patient motivations will not only create meaningful engagement opportunities for patients but will also enable health organizations to gain from the experience of these individuals. While further research is needed to support the engagement of diverse groups of stakeholders, the findings from this study have developed an understanding of how patients are motivated to make engagement decisions. This knowledge will help focus patient engagement efforts, thereby improving the efficiency and cost effectiveness of these programs, ensuring their relative sustainability.